重度颅脑损伤的营养支持治疗
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摘要
早在1975年，有文献证实颅脑损伤所导致的高代谢状态。现在肠内和肠外营养已经成为临床医生对早期重度脑损伤病人进行治疗的重要考虑内容。国内在这方面的研究起步较晚，开始于80～90年代。目前研究多局限于某个指标的研究和临床营养治疗的观察，系统性的基础研究尚未见到报道。
营养评定是通过人体组成测定、人体测量、生化检查、临床检查以及多项综合营养评定方法等手段，判定人体营养状况，确定营养不良的类型和程度，估计营养不良所致的严重后果，并监测营养支持的疗效。重度颅脑损伤病人在受伤以后，全身代谢立即发生明显改变。机体处于高分解状态，分解代谢明显高于合成代谢，非外源性营养所能纠正。具体表现为：高能量代谢；高分解代谢；糖耐受力降低；呈负氮平衡状态。重型颅脑损伤病人的静息能量消耗可以达到相同年龄、性别、体表面积未受伤人的168％±37％。糖代谢表现为：血糖上升，糖耐受力下降，对糖负荷的反应性降低。糖含量可较正常时增加150％～200％或是糖的生成量可达2～5mg·kg-1·min-1。重型颅脑损伤病人蛋白质代谢的表现为：蛋白质分解代谢加快，组织成分丢失，绝对负氮平衡，氮排出量增加。脂肪是创伤病人的主要能量来源。重度脑损伤病人脂肪分解增加，脂肪酸增加。最后，由于作为运输载体的血浆白蛋白减少，肝脏摄取和利用率增加，以及储存甘油三酯的释放减少，血浆游离脂肪酸减少。皮质类固醇能增加病人的感染机率，加重分解代谢，加重应激性溃疡。镇静剂与肌松剂使病人能量代谢消耗显著降低，但是仍然比正常人高出20～30％。低温治疗时，病人全身各系统代谢率均显著下降。
营养支持的目的是减轻营养底物的不足，防止细胞代谢紊乱，参与机体调控免疫与生理机能，支持器官、组织的结构和功能。在创伤后期，营养支持的目的是进一步加速组织的修复，促进病人的康复。营养支持分为两个方面：代谢支持和代谢调节。代谢支持要求非蛋白质热量应该小于35kcal／day，糖与脂肪在非蛋白热量中应各占50％左右。代谢支持分为肠外营养和肠内营养。进行营
中文摘要
养支持应该在伤后24一48小时以上开始进行。肠外营养适用于早期胃肠功能未
恢复的病人。重度颅脑损伤病人的肠外营养支持治疗主要是通过鼻胃管、鼻肠
管、咽造口、胃造痰、空肠造痰、经皮内窥镜胃造痰术等进行。投给方式主要
为连续输注法。目前，重度颅脑损伤病人进行营养支持的主要困难:l、难以准
确评估热量消耗;不能有效地改善分解代谢;生长激素加重高血糖;应用营养
支持的时机、时间、方式仍有争论;相关的基础研究较少;缺乏大规模、多中
心、随机、双盲试验进一步证实。
The earliest study of metabolic changes in the severe acute brain damage was reported in 1975. Today, enteral nutrition and exteral nutrition are wildly clinical used in western countries. In China, the study of nutritional support of severe head injured patients started at 1980's. Until recently, most of the studies are only limited in clinical observations.
Nutrition assessment is to estimate the nutritional status by body measurement, body composition, biochemical measurement and clinical check, total lymphocyte count(TLC), skin delayed hypersensitivity(SDH), and other ways. Nutrition assessment is usually used to estimate degrees of malnutrition and the results of nutritional support. Malnutrition usually points to protein energy malnutrition (PEM),includes adult maramus, Kwashiorkor and mixed marasmus and malnutrutiion.
Metabolic changes of head injured patients mainly include :highly catabolism, disturbance of carbohydrate metabolism, negative nitrogen balance. The aim of nutritional support of severe head injured patients is metabolic support and metabolic adjustment. Metabolic support requests 35kcal/day energy supply and 10-15g protein supply every day. Parenteral nutrition is only used in early head injured patients with gastrointestinal function problems. Enteral nutrition is used in most patients.
The main problems : It is difficult to estimate the really energy consumption of severe head injured patients. The results usually different from the really status; Basic studies are still not enough yet ; Clinically results of nutritional support therapy of severe head injured patients are still not certain.
营养评定是通过人体组成测定、人体测量、生化检查、临床检查以及多项综合营养评定方法等手段，判定人体营养状况，确定营养不良的类型和程度，估计营养不良所致的严重后果，并监测营养支持的疗效。重度颅脑损伤病人在受伤以后，全身代谢立即发生明显改变。机体处于高分解状态，分解代谢明显高于合成代谢，非外源性营养所能纠正。具体表现为：高能量代谢；高分解代谢；糖耐受力降低；呈负氮平衡状态。重型颅脑损伤病人的静息能量消耗可以达到相同年龄、性别、体表面积未受伤人的168％±37％。糖代谢表现为：血糖上升，糖耐受力下降，对糖负荷的反应性降低。糖含量可较正常时增加150％～200％或是糖的生成量可达2～5mg·kg-1·min-1。重型颅脑损伤病人蛋白质代谢的表现为：蛋白质分解代谢加快，组织成分丢失，绝对负氮平衡，氮排出量增加。脂肪是创伤病人的主要能量来源。重度脑损伤病人脂肪分解增加，脂肪酸增加。最后，由于作为运输载体的血浆白蛋白减少，肝脏摄取和利用率增加，以及储存甘油三酯的释放减少，血浆游离脂肪酸减少。皮质类固醇能增加病人的感染机率，加重分解代谢，加重应激性溃疡。镇静剂与肌松剂使病人能量代谢消耗显著降低，但是仍然比正常人高出20～30％。低温治疗时，病人全身各系统代谢率均显著下降。
营养支持的目的是减轻营养底物的不足，防止细胞代谢紊乱，参与机体调控免疫与生理机能，支持器官、组织的结构和功能。在创伤后期，营养支持的目的是进一步加速组织的修复，促进病人的康复。营养支持分为两个方面：代谢支持和代谢调节。代谢支持要求非蛋白质热量应该小于35kcal／day，糖与脂肪在非蛋白热量中应各占50％左右。代谢支持分为肠外营养和肠内营养。进行营
中文摘要
养支持应该在伤后24一48小时以上开始进行。肠外营养适用于早期胃肠功能未
恢复的病人。重度颅脑损伤病人的肠外营养支持治疗主要是通过鼻胃管、鼻肠
管、咽造口、胃造痰、空肠造痰、经皮内窥镜胃造痰术等进行。投给方式主要
为连续输注法。目前，重度颅脑损伤病人进行营养支持的主要困难:l、难以准
确评估热量消耗;不能有效地改善分解代谢;生长激素加重高血糖;应用营养
支持的时机、时间、方式仍有争论;相关的基础研究较少;缺乏大规模、多中
心、随机、双盲试验进一步证实。
The earliest study of metabolic changes in the severe acute brain damage was reported in 1975. Today, enteral nutrition and exteral nutrition are wildly clinical used in western countries. In China, the study of nutritional support of severe head injured patients started at 1980's. Until recently, most of the studies are only limited in clinical observations.
Nutrition assessment is to estimate the nutritional status by body measurement, body composition, biochemical measurement and clinical check, total lymphocyte count(TLC), skin delayed hypersensitivity(SDH), and other ways. Nutrition assessment is usually used to estimate degrees of malnutrition and the results of nutritional support. Malnutrition usually points to protein energy malnutrition (PEM),includes adult maramus, Kwashiorkor and mixed marasmus and malnutrutiion.
Metabolic changes of head injured patients mainly include :highly catabolism, disturbance of carbohydrate metabolism, negative nitrogen balance. The aim of nutritional support of severe head injured patients is metabolic support and metabolic adjustment. Metabolic support requests 35kcal/day energy supply and 10-15g protein supply every day. Parenteral nutrition is only used in early head injured patients with gastrointestinal function problems. Enteral nutrition is used in most patients.
The main problems : It is difficult to estimate the really energy consumption of severe head injured patients. The results usually different from the really status; Basic studies are still not enough yet ; Clinically results of nutritional support therapy of severe head injured patients are still not certain.
引文
1. Drew JH, Koop CE, Grigger RP. A nutritional study of neurosurgical patients. J Neurosury, 1947, 4: 7
2. Haider W, Lackner F, Schlick W, et al. Metabolic change in the course of severe acute brain damage. Eur J Intens Care Med, 1975, 1: 19
3．于康 王秀荣 蒋朱明．住院病人营养状况的评定．见：蒋朱明 蔡威．主编．北京：临床肠内与肠外营养．科学技术文献出版社，2000．174．
4．陈强谱主编．临床肠内营养，北京：人民卫生出版社
5．黎介寿主编．临床肠外与肠内营养支持．北京：人民军医出版社，1993．28
6．邵继智 顾景范 张思源主编．经肠营养．北京：军事医学科学出版社，1999．
7．江基尧 朱诚主编．颅脑创伤临床救治指南．上海：第二军医大学出版社．2002．158
8. Ott L, Young B, McClain C. The metabolic response to brain injury. J Parenteral Enteral Nutr, 1987, 11: 488
9. Clifton GL, Robertson CS, Choi SC. Assessment of nutritional requirements of head injured patients. J Neurosugry, 1986, 64(11): 895
10. Jonathan M, AnnaM. Lower esophageal sphincter dysfunction precludes safe gastric feeding after head injury. J Trauma, 1994, 37(10): 581
11．Jhon Rombeau，MD等．神经系统疾病的营养支持．见：蒋朱明 蔡威．主编．北京：临床肠内与肠外营养．科学技术文献出版社，2000．491．
12. Militsa B. Nutrition in neurologic and neurosurgical critical care. Neuol-India. 2001 Jun; 49 Suppl 1: S75-9
13．黎介寿．严重创伤病人营养支持的研究进展。中华创伤杂忠．1999，15：405-406
14. Guy L. The metabolic response to severe head injury. J neurosurg. 1984, 60: 687-696
15．胡卫星、顾培元、吴幼章，等．实验性脑损伤超急性期脑糖代谢的变化。中
华实验外科杂志，1998，11(6)：553-554
16．刘信龙、江基尧，杨中坚，等．大鼠液压颅脑伤后血糖、脑脊液乳酸和局部脑血流的改变。中华神经外科杂志，1994，11：353—354
17. A. Byron Yong. The acute-phase response of the brain-injured patient. J Neurosurg. 1988, 69: 375-380
18. Kiver K F et al. Pre- and postpyloric enteral feeding: analysis of safety and complications. J Parent Enter Nutr, 1984; 8: 679
19. Wilmore DW. Postperative protein sparing. World J Surg, 1999, 23: 545-552.
20．张时纯．胃肠插管术之临床应用．外科学报，1952，2：331
21. Ruan J A,. Interjojunal feeding: development and current status. JPEN, 1984: 8: 187
22. Martin D, Jastram C W. Enteral nutrition. Part Ⅱ: Nutr Supp Serv, 1987; 7; 8
23. Hoyt D et al. Head injury: an immuneologic in T-cell activation. J Trauma, 1990; 30: 759
24. Baskin WN. Advances in enteral nurtrition techniques. Am J Gastroenterol, 1992, 87: 1547
25. Norton JA, Ott LG, McClian C et al. Intolerance to enteral feeding in the brain-injured patient. J Nrueosurg, 1988, 68: 62
26. Lansdown AB. Zinc in the healing wound. Lancet, 1996, 347: 706
27. Moor FA. Issue in nutrition management of critically ill patients. Nutr Clin Prac, 1994, 9: 25
28. Shills ME, Olson JA, Shike M. modern Nutrition inhealth and disease. 8th ed, Philadelphia: Lea& Febiger, 1994: 477-485
29. Goulet O. Recent studies on small intestinal transplantation. Gurrent Opinion in Gastroenterology, 1997, 13: 500
30. Kitamura K, Yamaguchi T, Tanaka H, et al. PN-induced fulminant beriberi: a report on experience and a review of the literature. Surg today, 1996,26:769-776
31. Rombeau JL, Caldwell MD. Enteral and tube feeding. 2nd Editon. Philadelphia: WB Saunders Co., 1997
32. Rapp R P et al. The favorable effect of early parenteral feeding on survival in head-injured patients. J Neurosurg, 1983;58:906
2. Haider W, Lackner F, Schlick W, et al. Metabolic change in the course of severe acute brain damage. Eur J Intens Care Med, 1975, 1: 19
3．于康 王秀荣 蒋朱明．住院病人营养状况的评定．见：蒋朱明 蔡威．主编．北京：临床肠内与肠外营养．科学技术文献出版社，2000．174．
4．陈强谱主编．临床肠内营养，北京：人民卫生出版社
5．黎介寿主编．临床肠外与肠内营养支持．北京：人民军医出版社，1993．28
6．邵继智 顾景范 张思源主编．经肠营养．北京：军事医学科学出版社，1999．
7．江基尧 朱诚主编．颅脑创伤临床救治指南．上海：第二军医大学出版社．2002．158
8. Ott L, Young B, McClain C. The metabolic response to brain injury. J Parenteral Enteral Nutr, 1987, 11: 488
9. Clifton GL, Robertson CS, Choi SC. Assessment of nutritional requirements of head injured patients. J Neurosugry, 1986, 64(11): 895
10. Jonathan M, AnnaM. Lower esophageal sphincter dysfunction precludes safe gastric feeding after head injury. J Trauma, 1994, 37(10): 581
11．Jhon Rombeau，MD等．神经系统疾病的营养支持．见：蒋朱明 蔡威．主编．北京：临床肠内与肠外营养．科学技术文献出版社，2000．491．
12. Militsa B. Nutrition in neurologic and neurosurgical critical care. Neuol-India. 2001 Jun; 49 Suppl 1: S75-9
13．黎介寿．严重创伤病人营养支持的研究进展。中华创伤杂忠．1999，15：405-406
14. Guy L. The metabolic response to severe head injury. J neurosurg. 1984, 60: 687-696
15．胡卫星、顾培元、吴幼章，等．实验性脑损伤超急性期脑糖代谢的变化。中
华实验外科杂志，1998，11(6)：553-554
16．刘信龙、江基尧，杨中坚，等．大鼠液压颅脑伤后血糖、脑脊液乳酸和局部脑血流的改变。中华神经外科杂志，1994，11：353—354
17. A. Byron Yong. The acute-phase response of the brain-injured patient. J Neurosurg. 1988, 69: 375-380
18. Kiver K F et al. Pre- and postpyloric enteral feeding: analysis of safety and complications. J Parent Enter Nutr, 1984; 8: 679
19. Wilmore DW. Postperative protein sparing. World J Surg, 1999, 23: 545-552.
20．张时纯．胃肠插管术之临床应用．外科学报，1952，2：331
21. Ruan J A,. Interjojunal feeding: development and current status. JPEN, 1984: 8: 187
22. Martin D, Jastram C W. Enteral nutrition. Part Ⅱ: Nutr Supp Serv, 1987; 7; 8
23. Hoyt D et al. Head injury: an immuneologic in T-cell activation. J Trauma, 1990; 30: 759
24. Baskin WN. Advances in enteral nurtrition techniques. Am J Gastroenterol, 1992, 87: 1547
25. Norton JA, Ott LG, McClian C et al. Intolerance to enteral feeding in the brain-injured patient. J Nrueosurg, 1988, 68: 62
26. Lansdown AB. Zinc in the healing wound. Lancet, 1996, 347: 706
27. Moor FA. Issue in nutrition management of critically ill patients. Nutr Clin Prac, 1994, 9: 25
28. Shills ME, Olson JA, Shike M. modern Nutrition inhealth and disease. 8th ed, Philadelphia: Lea& Febiger, 1994: 477-485
29. Goulet O. Recent studies on small intestinal transplantation. Gurrent Opinion in Gastroenterology, 1997, 13: 500
30. Kitamura K, Yamaguchi T, Tanaka H, et al. PN-induced fulminant beriberi: a report on experience and a review of the literature. Surg today, 1996,26:769-776
31. Rombeau JL, Caldwell MD. Enteral and tube feeding. 2nd Editon. Philadelphia: WB Saunders Co., 1997
32. Rapp R P et al. The favorable effect of early parenteral feeding on survival in head-injured patients. J Neurosurg, 1983;58:906